Vivek Parwani

Practicing Paramedics Cannot Generate or Estimate Safe Endotracheal Tube Cuff Pressure Using Standard Techniques

Objectives. We sought to determine the ability of paramedics to inflate endotracheal tube cuffs within safe pressure limits as well as to estimate the pressure of previously inflated endotracheal tube cuffs by palpation of the pilot balloon. Methods. Using a tracheal simulation model, we conducted a prospective, observational, cross-sectional simulation study of licensed, practicing paramedics. This included evaluation of their ability to inflate the cuff of an endotracheal tube to a safe pressure, defined as ≤ 25 cm H2O, as well as to identify excessive intracuff pressure in previously inflated ETT cuffs by palpation of the pilot balloon. Results. Fifty-three paramedics were sampled. The average pressure generated by inflating the endotracheal tube cuff was > 108 cm H2O. Participants were only 13% sensitive detecting over inflated endotracheal tube cuffs (95% CI 7.3–17.8). Conclusions. Participants were unable to inflate endotracheal tube cuff to safe pressures andwere unable to identify endotracheal tube cuffs with excessive intracuff pressure by palpation. Clinicians should consider using devices such as manometers to facilitate safe inflation andaccurate measurement of endotracheal tube cuff pressure.

Evaluation of an Asynchronous Physician Voicemail Sign-out for Emergency Department Admissions

STUDY OBJECTIVE Communication failures contribute to errors in the transfer of patients from the emergency department (ED) to inpatient medicine units. Oral (synchronous) communication has numerous benefits but is costly and time consuming. Taped (asynchronous) communication may be more reliable and efficient but lacks interaction. We evaluate a new asynchronous physician-physician sign-out compared with the traditional synchronous sign-out. METHODS A voicemail-based, semistructured sign-out for routine ED admissions to internal medicine was implemented in October 2007 at an urban, academic medical center. Outcomes were obtained by pre- and postintervention surveys of ED and internal medicine house staff, physician assistants, and hospitalist attending physicians and by examination of access logs and administrative data. Outcome measures included utilization; physician perceptions of ease, accuracy, content, interaction, and errors; and rate of transfers to the ICU from the floor within 24 hours of ED admission. Results were analyzed both quantitatively and qualitatively with standard qualitative analytic techniques. RESULTS During September to October 2008 (1 year postintervention), voicemails were recorded about 90.3% of medicine admissions; 69.7% of these were accessed at least once by admitting physicians. The median length of each sign-out was 2.6 minutes (interquartile range 1.9 to 3.5). We received 117 of 197 responses (59%) to the preintervention survey and 113 of 206 responses (55%) to the postintervention survey. A total of 73 of 101 (72%) respondents reported dictated sign-out was easier than oral sign-out and 43 of 101 (43%) reported it was more accurate. However, 70 of 101 (69%) reported that interaction among participants was worse. There was no change in the rate of ICU transfer within 24 hours of admission from the ED in April to June 2007 (65/6,147; 1.1%) versus April to June 2008 (70/6,263; 1.1%); difference of 0%, 95% confidence interval -0.4% to 0.3%. The proportion of internists reporting at least 1 perceived adverse event relating to transfer from the ED decreased a nonsignificant 10% after the intervention (95% confidence interval -27% to 6%), from 44% preintervention (32/72) to 34% postintervention (23/67). CONCLUSION Voicemail sign-out for ED-internal medicine communication was easier than oral sign-out without any change in early ICU transfers or the perception of major adverse events. However, interaction among participants was reduced. Voicemail sign-out may be an efficient means of improving sign-out communication for stable ED admissions.

Recommended modifications and applications of the Hospital Emergency Incident Command System for hospital emergency management.

The Hospital Emergency Incident Command System (HEICS), now in its third edition, has emerged as a popular incident command system model for hospital emergency response in the United States and other countries. Since the inception of the HEICS in 1991, several events have transformed the requirements of hospital emergency management, including the 1995 Tokyo Subway sarin attack, the 2001 US anthrax letter attacks, and the 2003 Severe Acute Respiratory Syndrome (SARS) outbreaks in eastern Asia and Toronto, Canada. Several modifications of the HEICS are suggested to match the needs of hospital emergency management today, including: (1) an Incident Consultant in the Administrative Section of the HEICS to provide expert advice directly to the Incident Commander in chemical, biological, radiological, nuclear (CBRN) emergencies as needed, as well as consultation on mental health needs; (2) new unit leaders in the Operations Section to coordinate the management of contaminated or infectious patients in CBRN emergencies; (3) new unit leaders in the Operations Section to coordinate mental health support for patients, guests, healthcare workers, volunteers, and dependents in terrorism-related emergencies or events that produce significant mental health needs; (4) a new Decedent/Expectant Unit Leader in the Operations Section to coordinate the management of both types of patients together; and (5) a new Information Technology Unit Leader in the Logistics Section to coordinate the management of information technology and systems. New uses of the HEICS in hospital emergency management also are recommended, including: (1) the adoption of the HEICS as the conceptual framework for organizing all phases of hospital emergency management, including mitigation, preparedness, response, and recovery; and (2) the application of the HEICS not only to healthcare facilities, but also to healthcare systems. Finally, three levels of healthcare worker competencies in the HEICS are suggested: (1) basic understanding of the HEICS for all hospital healthcare workers; (2) advanced understanding and proficiency in the HEICS for hospital healthcare workers likely to assume leadership roles in hospital emergency response; and (3) special proficiency in constituting the HEICS ad hoc from existing healthcare workers in resource-deficient settings. The HEICS should be viewed as a work in progress that will mature as additional challenges arise and as hospitals gain further experience with its use.

Pilot test of a proposed chemical/biological/radiation/ nuclear-capable mass casualty triage system

Introduction. Existing mass casualty triage systems do not consider the possibility of chemical, biological, or radiologic/nuclear (CBRN) contamination of the injured patients. A system that can triage injured patients who are or may be contaminated by CBRN material, developed through expert opinion, was pilot-tested at an airport disaster drill. The study objective was to determine the systems speed andaccuracy. Methods. For a drill involving a plane crash with release of organophosphate material from the cargo hold, 56 patient scenarios were generated, with some involving signs andsymptoms of organophosphate toxicity in addition to physical trauma. Prior to the drill, the investigators examined each scenario to determine the “correct” triage categorization, assuming proper application of the proposed system, andtrained the paramedics who were expected to serve as triage officers at the drill. During the drill, the medics used the CBRN triage system to triage the 56 patients, with two observers timing andrecording the events of the triage process. The IRB deemed the study exempt from full review. Results. The two triage officers applied the CBRN system correctly to 49 of the 56 patients (87.5% accuracy). One patient intended to be T2 (yellow) was triaged as T1 (red), for an over-triage rate of 1.8%. Five patients intended to be T1 were triaged as T2, andone patient intended to be T2 was triaged as T3 (green), for an under-triage rate of 10.7%. All six under-triage cases were due to failure to recognize or account for signs of organophosphate toxidrome in applying the triage system. For the 27 patients for whom times were recorded, triage was accomplished in a mean of 19 seconds (range 4-37, median 17). Conclusions. The chemical algorithm of the proposed CBRN-capable mass casualty triage system can be applied rapidly by trained paramedics, but a significant under-triage rate (10.7%) was seen in this pilot test. Further refinement andtesting are needed, andeffect on outcome must be studied.

Is there a role for first responders in EMS responses to medical facilities

Objective: Emergency medical dispatch (EMD) protocols should match response resources with patient needs. We tested a protocol sending only a commercial ambulance, without fire department first responders (FR), to all non-cardiac-arrest EMS calls at a physician-staffed HMO facility. Study objectives were to determine how often FR provided patient care at such facilities andwhether EMD implementation could conserve FR resources without compromising patient care. Methods: All EMS dispatches to this facility in the 4 months before implementation of the EMD protocol and4 months after implementation were identified through dispatch records, andall FR andambulance patient care reports were reviewed. In the “after” phase, all cases needing ALS transport were reviewed to examine whether there would have been benefit to FR dispatch. Results: Of 242 dispatches in the “before” phase, BLS FR responded to 156 (64%), andALS FR to 117 (48%). BLS FR provided patient care in 2 cases, andALS FR in 17. Of 227 dispatches in the “after” phase, BLS FR responded to 10 (4%), andALS FR to 10 (4%); all but one were protocol violations. BLS FR provided care in one case, andALS FR in three. Review of the 93 “after” cases requiring ALS transport found none where FR presence would have been beneficial. Conclusions: First responders rarely provided patient care when responding to EMS calls at a physician-staffed medical facility. Implementation of an EMD protocol can safely reduce the number of FR responses to unscheduled ambulance calls at such a facility. Key words: emergency medical services; dispatch.

Threats to Life in Residential Structure Fires

Introduction. Firefighters are taught that heat, oxygen deprivation, andcarbon monoxide (CO) are the primary threats to life in residential structure fires, andthey are taught to search for victims on the fire floor first, andthen floors above. The objective of this study was to gather data regarding oxygen, CO, andheat conditions inside a realistic house fire, to examine the validity of these teachings. Methods. During six live-burn training evolutions in a two-story wood-frame house, metering for oxygen levels, CO levels, andtemperature was conducted. Except where noted, all readings were taken 24 inches off the floor, to simulate the location of a crawling victim or firefighter. Readings were hand-recorded on a convenience basis by firefighters stationed outside the building, near the meters. Results. Of the 35 oxygen levels recorded, the lowest was 18.2%, with only 12 readings below 20%. Three of 16 first-floor readings were below 20%, whereas nine of 19 second-floor readings were below 20% (p = 0.07). First- andsecond-floor readings were comparable (mean 20.3% vs. 19.9%, p = 0.11). Except for one reading of 1,870 ppm, all CO readings at the ceiling exceeded the 2,000-ppm limit of the meters. Of the 34 CO levels recorded 24 inches off the floor, 29 (76%) exceeded the permissible exposure limit of 50 ppm, with the highest reading being 1,424 ppm, well above the “immediately dangerous to life andhealth” level of 1,200 ppm. None of the 20 CO levels recorded on the first floor exceeded the 30-minute exposure limit of 800 ppm, whereas seven of 14 second-floor readings exceeded this limit (p < 0.001). While ceiling temperatures frequently exceeded the 1,000°F limit of the meters, none of 16 readings taken 24 inches off the floor exceeded 137°F. First- andsecond-floor temperatures were comparable (mean 88.5°F vs. 90.1°F, p = 0.9). Conclusions. In residential structure fires, CO poses a greater threat to victims andfirefighters than does oxygen deprivation or heat. Emergency medical services personnel should consider CO toxicity in all fire victims. Conditions on the floor above a fire are at least as adverse as those on the fire floor.

Insurance Status and Access to Urgent Primary Care Follow-up After an Emergency Department Visit in 2016

Study objective: We examine the availability of follow‐up appointments for emergency department (ED) patients without established primary care by insurance and clinical condition. Methods: We used “secret shopper” methodology, employing 2 black men to telephone all 53 primary care practices in greater New Haven, posing as new patients discharged from the ED and requesting follow‐up appointments. Each practice received 6 scripted calls from each caller during an 8‐month period, reflecting all possible scenarios based on 3 insurance types (Medicaid, state exchange, and commercial) and 2 conditions (hypertension and back pain). Primary outcome was the proportion of calls that obtained an appointment in 7 calendar days (7‐day appointment rate). Secondary outcomes included overall appointment rate and appointment wait time. Results: Among the total of 604 calls completed, the 7‐day appointment rate was 30.7% (95% confidence interval [CI] 22.6% to 38.8%). Compared with commercial insurance, Medicaid calls had lower 7‐day rate (25.5% versus 35.7%; difference 10.2%; 95% CI 2.2% to 18.1%) and overall appointment rate (53.5% versus 77.8%; difference 24.4%; 95% CI 13.4% to 35.4%). There was no significant difference between state exchange and commercial insurance calls in 7‐day rate (30.9% versus 35.7%; difference 4.8%; 95% CI –3.1% to 12.6%) or overall appointment rate (73.4% versus 77.8%; difference 4.4%; 95% CI –2.7% to 11.6%). Back pain, compared with hypertension, had lower 7‐day appointment rate (27.6% versus 33.7%; difference 6.1%; 95% CI 1.0% to 11.2%), but no significant difference in overall appointment rates (67.0% versus 69.4%; difference 2.4%; 95% CI –2.7% to 7.5%). Conclusion: For patients without established primary care, obtaining timely follow‐up after acute care in the ED is difficult, particularly for Medicaid beneficiaries.

Emergency physicians cannot inflate or estimate endotracheal tube cuff pressure using standard techniques

Study objectives: Tracheal necrosis and stenosis may result from an overinflated endotracheal tube cuff. Safe, appropriate pressure in endotracheal tube cuffs is considered to be between 15 and 25 cm H2O, pressures below normal capillary perfusion pressure. We seek to determine the ability of emergency medicine residents and attending physicians in accredited emergency medicine residency training programs to inflate an endotracheal tube cuff to appropriate pressure using standard syringe technique and assess appropriateness of pressure of previously inflated endotracheal tube cuffs by palpating the pilot balloon. Methods: This institutional review board–approved descriptive survey of resident and attending physicians in accredited emergency medicine residency training programs in New York City used a previously tested, tracheal simulation model with a 7.5-mm endotracheal tube with a high-volume low-pressure cuff (Mallinkrodt, St. Louis, MO). Using their choice of a 5-mL or 10-mL plastic syringe with standard Luer Lock (Beckton-Dickson, Franklin Lakes, NJ), participants inflated the endotracheal tube cuff by standard method of injecting air as they deemed appropriate in conjunction with palpating the pilot balloon to estimate cuff pressure. Subsequently, the endotracheal tube cuff pressure was measured using a highly sensitive and accurate analog manometer (Boehringer Laboratories, Norristown, PA). Later, participants palpated the pilot balloon of 9 endotracheal tubes with cuffs previously inflated to known pressures ranging from 0 to 120 cm H2O and reported whether the pressure was low, appropriate, or high. Results: Twenty-five resident physicians and 42 attending physicians from 5 emergency medicine residency training programs were surveyed. Only 0.4% (n=3) of participants inflated the cuff to a safe pressure; all were attending physicians. The average cuff pressure generated by emergency medicine attending physicians was greater than 98 cm H2O (attending physicians >93 cm H2O, residents >106 cm H2O). The true mean could not be determined because 57% (n=38) inflated to pressures greater than the upper limit of manometer sensitivity (>120 cm H2O). Using palpation, participants were only 33% sensitive detecting inappropriately inflated endotracheal tube cuffs (attending physicians 22% sensitive, residents 53% sensitive), and they were only 26% sensitive in detecting overinflated endotracheal tube cuffs (attending physicians 22%, residents 33%). Average experience as an attending emergency physician was 9 years; average experience as a resident was 2.1 years. Conclusion: This group of emergency physicians had little ability to inflate an endotracheal tube cuff to safe pressure, little ability to accurately estimate pressure of a previously inflated cuff using standard technique, and minimal ability to detect overinflated endotracheal tube cuffs. Nearly all inflated the cuff to dangerously high pressures. Clinicians should consider using devices that permit safe and accurate inflation and measurement of endotracheal tube cuff pressure rather than relying on standard palpation technique, which is potentially unsafe and highly inaccurate.

GRADUATINGPARAMEDICSTUDENTS AREUNABLE TOESTIMATEENDOTRACHEALTUBECUFFPRESSURE BYSTANDARDPALPATIONTECHNIQUE

and the proportion of trip sheets specifically documenting Viagra use. Data were considered significantly different if p, 0.05. Results: There was a significant increase in the number of subjects receiving aspirin over time (pre = 52.3%, post1 = 65.8%, post2 = 82.8%). No changes were noted in the documentation of Viagra use (pre = 18.2%, post1 = 15.2%, post2 = 15.4%). Additionally, no changes were noted in the rate of oxygen administration, establishing intravenous access, cardiac monitoring, or 12-lead ECG. Conclusions: A simple prehospital intervention in the form a printed reminder placed on the nitroglycerin bottle increased the rate of aspirin administration for cardiac chest pain for three months. The documentation of Viagra use did not improve during the same period of time, although we cannot determine from trip sheet analysis if subjects were asked about Viagra use without subsequent documentation.

87 Surprise Bill? Am I Covered? A Secret Shopper’s Perspective

obstetrical emergencies were levied against individual physicians and the remaining 35 (92%) were levied against hospitals. Of 8 total CMPs levied against individual physicians during the study period, 3 (37.5%) were related to obstetrical cases, including 2 against obstetricians, 1 of whom failed to respond to a request to evaluate and treat a pregnant patient with preeclampsia, and another who failed to provide appropriate medical screening examination, stabilizing treatment, and appropriate transfer for a pregnant woman in labor. The third case involved an emergency physician who repeatedly failed to provide medical screening exam and stabilizing treatment to a pregnant minor with vaginal bleeding. Of 38 penalties related to obstetrical emergencies, 15 (40%) occurred in CMS region IV, and 8 (21%) in CMS region VI. Eight of 15 (53%) settlements in CMS region IV occurred in Florida, and 5 of 8 (63%) in CMS region VI occurred in Texas. The average CMP settlement amount for obstetrical-related cases (